Economic evaluation of mindfulness group therapy for patients with depression, anxiety, stress and adjustment disorders compared with treatment as usual.

BACKGROUND: A randomised controlled trial found that a structured mindfulness group therapy (MGT) programme was as effective as treatment as usual (mostly cognitive-behavioural therapy) for patients with a diagnosis of depression, anxiety or stress and adjustment disorders in Sweden (ClinicalTrials.gov: NCT01476371). AIMS: To perform a cost-effectiveness analysis of MGT compared with treatment as usual from both a healthcare and a societal perspective for the trial duration (8 weeks). METHOD: The costs from a healthcare perspective included treatment as usual, medication and costs for providing MGT. The societal perspective included costs from the healthcare perspective plus savings from productivity gains for the trial duration. The effectiveness was measured as quality-adjusted life-years (QALY) using the EQ-5D-5L questionnaire and the UK value set. Uncertainty surrounding the incremental costs and effects were estimated using non-parametric bootstrapping with 5000 replications and presented with 95% confidence intervals and cost-effectiveness acceptability curves. RESULTS: The MGT group had significantly lower healthcare and societal costs (mean differences -€115 (95% CI -193 to -36) and -€112 (95% CI -207 to -17), respectively) compared with the control group. In terms of effectiveness, there was no significant difference in QALY gain (mean difference -0.003, 95% CI -0.0076 to 0.0012) between the two groups. CONCLUSIONS: MGT is a cost-saving alternative to treatment as usual over the trial duration from both a healthcare and a societal perspective for patients with a diagnosis of depression, anxiety or stress and adjustment disorders in Sweden.

Health care utilization and expenditures of persons with diabetes comorbid with anxiety disorder: a national population-based cohort study.

OBJECTIVE: The aim of this study was to investigate and compare health care utilization and expenditures between persons with diabetes comorbid with and without anxiety disorder in Taiwan. METHODS: Health care utilization and expenditures among persons with diabetes with and without comorbid anxiety disorder in the period 2000-2004 were examined using the Taiwan's National Health Insurance claims data. Health care utilization included outpatient visits and use of hospital inpatient services, while expenditures included outpatient, inpatient and total medical expenditures. General estimation equation (GEE) models were used to analyze the factors associated with outpatient visits and expenditures, and multiple logistic regression analysis was applied to identify factors associated with hospitalization. RESULTS: In the study period, the average number of annual outpatient visits was 43.11-50.37 and 29.82-31.42 for persons with diabetes comorbid with anxiety disorder and for those without anxiety disorder, respectively. The average annual total expenditure was NT$74,875-92,781 and NT$63,764-81,667, respectively. Controlling for covariates, the GEE models revealed that age and time were associated with outpatient visits. Income and time factor were associated with total expenditure. CONCLUSIONS: Health care utilization and expenditures for persons with diabetes with comorbid anxiety disorder are significantly higher than those without anxiety disorder. The factors associated with health care utilization and expenditures are age, income and time.

Economic Evaluation of Concise Cognitive Behavioural Therapy and/or Pharmacotherapy for Depressive and Anxiety Disorders.

BACKGROUND: Depressive and anxiety disorders cause great suffering and disability and are associated with high health care costs. In a previous conducted pragmatic randomised controlled trial, we have shown that a concise format of cognitive behavioural- and/or pharmacotherapy is as effective as standard care in reducing depressive and anxiety symptoms and in improving subdomains of general health and quality of life in secondary care psychiatric outpatients. AIMS OF THE STUDY: In this economic evaluation, we examined whether a favourable cost-utility of concise care compared to standard care was attained. METHODS: The economic evaluation was performed alongside a pragmatic randomised controlled trial. Health-related quality of life was measured using the Short-Form (SF-36) questionnaire. Cost of healthcare utilization and productivity loss (absenteeism and presenteeism) were assessed using the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). A cost-utility analysis, using cost-effectiveness acceptability curves, comparing differences in societal costs and Quality-Adjusted Life Years (QALYs) at 1 year was performed. RESULTS: One year after study entry, the difference in mean cost per patient of the two primary treatments was not significant between both groups. No significant differences in other healthcare and non- healthcare costs could be detected between patients receiving concise care and standard care. Also, QALYs were not statistically different between the groups during the study period. From both the societal and healthcare perspective, the probability that concise care is more cost-effective compared to standard care remains below the turning point of 0.5 for all acceptable values of the willingness to pay for a QALY. The economic evaluation suggests that concise care is unlikely to be cost-effective compared to standard care in the treatment for depressive- and anxiety disorders in secondary mental health care during a one year follow up period. DISCUSSION: Total costs and QALYs were not significantly different between standard and concise care, with no evidence for cost-effectiveness of concise care in the first year. The longer impact of concise care for patients with mild to moderate symptoms of depressive and/or anxiety disorders compared to standard care in secondary care needs to be further studied. IMPLICATIONS: This economic evaluation failed to find significant differences in cost between concise and standard care over the study period of one year. Replication of our economic evaluation might benefit from an extended follow-up period and strict adherence to the study protocol. If concise care will be found to be cost-effective in the long term, this would have major implications for recommendations how to optimize secondary mental health care in the treatment of depressive -- and anxiety disorders.

The costs associated with antidepressant use in depression and anxiety in community-living older adults.

OBJECTIVE: To determine the costs associated with antidepressant (AD) use by depression and anxiety status in a public-managed health care system. METHODS: Data were obtained from a population-based health survey of 1869 older adults. Depression and anxiety were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and measured at 2 time points 1 year apart. AD and health service use and costs were identified from provincial administrative databases and included hospitalizations, physician fees, outpatient medications, and ambulatory visits. Patient costs considered were related to drug copayments, transportation, and time spent seeking medical care. Annual costs associated with AD use were studied as a function of mental health status at baseline and follow-up interviews (persistence, incidence, remission, or no illness). Generalized linear models with a gamma distribution were used to control for individual factors. RESULTS: The costs incurred by participants using ADs as a whole (17.8%) reached $6678 (95% CI $5449 to $8182), significantly more than in participants not using ADs ($4698; 95% CI $3710 to $5949). AD use was associated with greater total adjusted costs among respondents with no depression (adjusted difference = $1769; 95% CI $236 to $3702) and no anxiety (adjusted difference = $1845; 95% CI $203 to $3486). CONCLUSION: The results showed that AD use was not associated with cost savings in any group, and indeed with greater costs among participants who were neither depressed nor anxious at any time point. Future cost studies may consider the analyses of different AD classes regarding the different clinical mental health profiles in older adults.

Modelling the cost-effectiveness of pregabalin versus usual care in daily practice in the treatment of refractory generalised anxiety disorder in Spain.

PURPOSE: To model the cost-effectiveness (CEA) of the use of pregabalin versus usual care (UC) in outpatients with refractory generalised anxiety disorder (GAD) treated in daily practice in mental health settings in Spain. METHODS: This CEA model used data extracted from a 6-month prospective non-interventional trial: the Amplification of Definition of ANxiety (ADAN) study, which was conducted to determine the cost-of-illness in GAD subjects. Refractory subjects were those who reported persistent symptoms of anxiety and showed suboptimal response in the Hamilton-anxiety scale (HAM-A ≥ 16) after a standard dose regimen of anxiolytics other than pregabalin, alone or in combination, over 6 months. The pregabalin arm was documented with data extracted from patients who received pregabalin in the study for the first time, added or replacing the existing therapy. In the UC arm, treatment might include one or more of the following: a serotonin selective reuptake inhibitor, a serotonin-norepinephrine reuptake inhibitor, other anti-depressants, a benzodiazepine or an anti-epileptic drug other than pregabalin. The time horizon of the modelling was 6 months in the base-case scenario, and the National Health System perspective was chosen to calculate costs. Effectiveness was expressed as quality-adjusted life years (QALYs) gained, which were derived using the EQ-5D questionnaire, at baseline and end-of-trial visits. Results of the CEA model was expressed as an incremental cost-effectiveness ratio (ICER) per QALY gained. Probabilistic sensitivity analysis using bootstrapping techniques was also carried out to obtain the cost-effectiveness plane and the corresponding acceptability curve. RESULTS: Data from a total of 429 subjects per arm (mean HAM-A score 25.7) meeting eligible criteria for inclusion in CEA modelling were extracted from the original trial. Compared with UC, pregabalin (average dose 218 mg/day) was associated with significantly higher QALY gain; 0.1209 ± 0.1030 versus 0.0994 ± 0.0979 (P = 0.003), but increased healthcare costs as well; 1,272 ± 1,240 versus 1,070 ± 1,177 (P < 0.069) and drug costs 525 ± 252 versus 219 ± 211 (P < 0.001), resulting in an ICER of 15,804/QALY (95 % CI 6,661; 37,186) for healthcare costs and 15,165/QALY (7,947; 31,754) when drug costs were considered alone. A total of 94 % of re-samples fell below the threshold of 30,000 per QALY. CONCLUSIONS: This evaluation modelling suggests that pregabalin may be cost-effective in comparison with UC in outpatients with refractory GAD treated in mental healthcare settings in daily practice in Spain.

Effect of visual art on patient anxiety and agitation in a mental health facility and implications for the business case.

There is a growing body of evidence on the impact of the environment on health and well-being. This study focuses on the impact of visual artworks on the well-being of psychiatric patients in a multi-purpose lounge of an acute care psychiatric unit. Well-being was measured by the rate of pro re nata (PRN) medication issued by nurses in response to visible signs of patient anxiety and agitation. Nurses were interviewed to get qualitative feedback on the patient response. Findings revealed that the ratio of PRN/patient census was significantly lower on the days when a realistic nature photograph was displayed, compared to the control condition (no art) and abstract art. Nurses reported that some patients displayed agitated behaviour in response to the abstract image. This study makes a case for the impact of visual art on mental well-being. The research findings were also translated into the time and money invested on PRN incidents, and annual cost savings of almost $US30,000 a year was projected. This research makes a case that simple environmental interventions like visual art can save the hospital costs of medication, and staff and pharmacy time, by providing a visual distraction that can alleviate anxiety and agitation in patients.

Crenotherapy: a neglected resource for human health now re-emerging on sound scientific concepts.

Recent mechanistic evidence demonstrates that spa-based therapy (or, as we propose, crenotherapy from the Greek word kapparhoepsilonnueta, spring fountain) is indeed based on solid scientific data. This mini-review highlights the latest insights into the mechanisms of crenotherapy derived from in vitro experiments, studies on animal models, and carefully designed clinical trials. Although more basic and clinical data are still needed, crenotherapy is coming of age as a modern, scientifically sound therapy. As the underlying mechanisms are uncovered, it is becoming possible to choose the most appropriate applications of this centuries-old practice, possibly reducing medical costs, thus explaining the current worldwide renewed interest in crenotherapy.

Cost-effectiveness of pregabalin versus venlafaxine in the treatment of generalized anxiety disorder: findings from a Spanish perspective.

The objective of the present study was to describe a new model of the cost-effectiveness of treatment of generalized anxiety disorder (GAD) and its application to a comparison of pregabalin versus venlafaxine extended-release (XR) from a Spanish healthcare perspective. Microsimulation techniques, including Hamilton Anxiety Scale (HAM-A) score, number of weeks with minimal or no anxiety (HAM-A

Outcomes of self-help efforts in anxiety disorders.

Anxiety disorders are prevalent mental disorders that are a significant burden on the community. There are effective treatments available, but many people do not seek treatment and there is a lack of professionals available to provide evidence-based treatment to all those with anxiety disorders. Recently, there has been increased attention on ways to cost effectively meet the demand for treatment with minimal cost to health services. Self-help efforts have been proposed to play a role, either as an initial minimal treatment in stepped-care models of treatment, or as strategies undertaken by an individual to prevent a full disorder developing. This review examines what is known from randomized controlled trials about the efficacy of self-help interventions for anxiety disorders.

Differences in total medical costs across the SSRIs for the treatment of depression and anxiety.

There is growing evidence that adherence to the recommended duration of antidepressant therapy results in reduced medical costs compared with nonadherence, and that the likelihood of adhering to therapy is not equivalent across the selective serotonin reuptake inhibitors (SSRIs). As such, the purpose of this study was to assess differences in 6-month medical costs between paroxetine controlled-release (CR) and immediate-release (IR) SSRI agents in a retrospective analysis of patients initiating SSRI therapy identified from the Integrated Healthcare Information Services National Managed Care Benchmark Database during a 2.5-year time frame. Inferential analyses were performed to evaluate differences in 6-month medical costs, controlling for differences in age, sex, utilization of psychiatric specialty care services, titration, pre-period costs, and comorbidity measures. Of the 146 075 patients included in this study, approximately 7% received paroxetine CR. Approximately 29.5% of patients had an anxiety disorder diagnosis; 26.0% had a depression-only diagnosis; and 13.2% had comorbid anxiety and depression. The 6-month medical costs were 244 US dollars lower for patients initiating with paroxetine CR compared with the average medical costs for patients receiving IR SSRIs. Paroxetine CR also had the lowest medical costs compared with each individual SSRI evaluated. After log transformation of costs and adjustment for baseline covariates, the aggregated IR SSRIs were associated with 8.7% higher 6-month medical costs than paroxetine CR (P <.001) and even greater costs after stratifying by diagnosis: 12.5% higher costs in patients with anxiety, 14.3% higher costs in patients with depression, and 15.9% higher costs in patients with comorbid anxiety and depression (P <.001 for all). Each individual IR SSRI was also associated with significantly higher medical costs than paroxetine CR, irrespective of diagnosis. As demonstrated, medical costs over a 6-month time frame were significantly greater for IR SSRIs versus paroxetine CR, even after adjusting for background characteristics and stratifying by diagnosis. Future studies should measure rates of adherence in relation to medical outcomes over an expanded time frame.

Adherence to paroxetine CR compared with paroxetine IR in a Medicare-eligible population with anxiety disorders.

There are many challenges in the pharmacologic management of elderly patients with anxiety disorders, including an increased sensitivity to drug effects, reduced drug metabolism, and socioeconomic barriers leading to poor medication adherence. As such, the purpose of this study was to evaluate differential rates of adherence between paroxetine controlled release (CR) and paroxetine immediate release (IR) in the treatment of anxiety disorders in a Medicare-eligible population. Patients aged 65 years or older initiating therapy with paroxetine CR or paroxetine IR with a diagnosis of anxiety were identified from the Integrated Healthcare Information Services National Managed Care Benchmark database from July 2001 to February 2004. Logistic regression models were used to assess differences in 6-month adherence rates, controlling for differences in multiple background characteristics. Adherence was defined as having a minimum medication possession ratio of 80% over 180 days without evidence of a 15-day gap before 90 days of therapy. Of the 604 patients included in the study, 18% received paroxetine CR and 82% received paroxetine IR; comorbid anxiety and depression were present in 37.3% of patients. Overall, only 37.3% of patients adhered to therapy, with a greater percentage of patients adhering to paroxetine CR (45.0%) compared with paroxetine IR (35.6%). After controlling for background characteristics, patients receiving paroxetine IR were 38.7% less likely to adhere to therapy compared with patients receiving paroxetine CR (P = .0328). When stratified by those with comorbid anxiety and depression, patients receiving paroxetine IR were 55.1% less likely to adhere to therapy compared with patients receiving paroxetine CR (P = .0292). This study demonstrates that antidepressant nonadherence is common in patients older than 65 years of age, with overall rates of nonadherence at 62.7% and patients receiving paroxetine IR having the lowest levels of adherence. Future work should assess differences in all available selective serotonin reuptake inhibitors while also directly assessing the economic impact of nonadherence in the elderly population.